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Epidural Injections (Steroids, Lidocaine, Opioids)  
Panel findings and recommendations: 
 -   There is no evidence to support the use of invasive epidural injections of steroids, local anesthetics, and/or opioids as a treatment for acute low back pain without radiculopathy.  (Strength of Evidence = D.) 
 -   Epidural steroid injections are an option for short-term relief of radicular pain after failure of conservative treatment and as a means of avoiding surgery.  (Strength of Evidence = C.) 
  Epidural injections for treating low back problems, done primarily in patients with suspected radiculopathy, involve the injection of medication (corticosteroids, local anesthetics, or narcotics) into the epidural space, near the site where the nerve roots pass before entering the intervertebral foramen.  In theory, injecting medication into the epidural space allows a concentrated amount of medication to be deposited and retained in a specific area, exposing the nerves to the medication for a prolonged period of time.  The therapeutic objective of epidural injections is to reduce swelling, inflammation, and pain. 
  There are various techniques for performing the epidural injection, some of which are more precise than others.198  According to White,199 placement of epidural needles is incorrect in 25 percent of the cases. 
Epidural Injections 
Literature Reviewed     Evidence on Efficacy   Potential Harms and Costs      Summary of Findings    Author's Example 
Epidural Injections 
  Literature Reviewed.  Of 74 articles screened for this topic, 9 RCTs met criteria for review.138, 200, 201, 202, 203, 204, 205, 206, 207 Other articles contained information used by the panel, but did not meet article selection criteria.147, 198, 199, 208, 209 
 Evidence on Efficacy.    Two studies evaluated patients with low back pain of less than 3 months' duration and also with radicular symptoms and findings suggesting nerve root dysfunction.138, 202  Both studies compared groups receiving epidural injections of steroids combined with local anesthetic to groups receiving injections of local anesthetic alone, either into the epidural space202 or into a tender spot over the sacrum.138 
  Cuckler, Bernini, Wiesel, et al.202 found no significant differences in pain relief between groups immediately posttreatment or at long-term followup (mean of 20 months).  Mathews, Mills, Jenkins, et al,138 found no significant differences in pain relief between groups at 1, 6, or 12 months followup, but the epidural steroid group did have significantly better results at 3 months followup. 
  The remaining seven studies evaluated groups with either chronic low back problems or a mix of acute and chronic problems.200, 201, 202, 203, 204, 205, 206, 207 Medications used and locations injected varied.  Four studies evaluated groups receiving epidural injections with various combinations of steroids, local anesthetics, and/or saline. 200, 201,207  Two studies evaluated groups receiving either epidural steroid injections or injections of saline into the interspinous ligament.204, 206  One study evaluated groups receiving epidural injections with various combinations of steroids and morphine.203 
  The five studies that reported on short-term pain relief at 2 to 4 weeks followup showed conflicting results.  For this time period, three studies reported significantly greater pain relief for the epidural steroid groups.201,204,206  The other two studies found no differences in pain relief between groups.205,207 
  Five studies reported on followup beyond 1 month. 200, 201, 204, 207 Only one found significantly greater pain relief for the epidural steroid group.200  The other studies found no significant differences in pain relief between groups.  One study did find that a significantly higher percentage of the group receiving epidural steroid injections had returned to work at 3 months.204  Three studies showed significantly better results within the first month for epidural steroids versus local anesthetic or saline injections, but not on longer followup.201, 204, 206 No significant differences were reported between groups at 3 months204 or at 1 year.201  Ridley, Kingsley, Gibson, et al.206 did not report followup beyond 2 weeks.  Two other studies found no significant differences in pain relief between groups for any followup period.205, 207  One study that evaluated epidural injections of morphine compared with (and/or in combination with) steroids found no significant differences in pain relief between groups on either short-term (within 1 month) or longer term followup.203 
  Potential Harms and Costs.  Reported complications of epidural injections are described by Kepes and Duncalf.208  The primary major complication reported was rare epidural abscess.  Minor transient complications included headache, fever, and inadvertent spinal tap.  Rocco, Frank, Kaul, et al.209 reported several cases of "life-threatening ventilatory depression" in patients who received epidural injections of morphine and steroids combined.  In 5 of the 19 times such injections were given, the patients experienced respiratory depression to the point of somnolence and had to receive naloxone for reversal of narcosis.  Also posttreatment, the respiratory rates of patients receiving epidural morphine were lower than for patients receiving epidural steroids alone. The lowest respiratory rates were seen in those receiving injections of morphine combined with steroids.  Mandell, Lipton, Bernstein, et al.147 described headache as the most common side effect of epidural steroid injections (presumably resulting from pressure changes in the epidural space or accidental puncture of the dura) and listed aseptic meningitis, infection, and neurologic problems as other possible complications. Epidural injections are considered an expensive treatment. 
  Summary of Findings.  Limited research evidence indicates that epidural injections using any type of medication lack proven efficacy for treating patients with low back pain without radiculopathy. More recent review indicate without radiculopathy, back pain is not improved by epidural glucocorticoids or anesthetic Injections (Nelemans`01).   Epidural injections are invasive and pose rare but serious potential risks. [Note 13.1% vascular injection when administered lumbar transforaminally (Smuck`07)] There was no evidence that epidural steroids are effective in treating acute radiculopathy, but the panel's opinion was that epidural steroid injections may be useful as an attempt to avoid surgery. 
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